Validation of HAI Reporting in New Hampshire Hospitals: Data from

Transcription

1 Validation of HAI Reporting in New Hampshire Hospitals: Data from Nancy Reinhalter, RN CCRC JSI Research & Training Institute, Inc. February 22, 2017

2 ACKNOWLEDGEMENTS JSI Team Priscilla Davis Paddy Dipadova Laurie Kunches Nancy Reinhalter Expert consultant: Cathy Korn RN, MPH, CIC (Boston Medical Center) We are very grateful to: NH DHHS HAI Program Katrina Hansen Yvette Perron Individual Infection Preventionists at NH hospitals

3 PROJECT OVERVIEW Our team previously conducted external validation of reported HAI data ( ) in NH acute care facilities; corrections resulted in 23% overall increase in reported events. This project used the same methods to validate an expanded list of HAIs across the 26 acute care facilities. Timeframe of data for large facilities was 2015; critical access hospitals also included 2014 data.

4 SUMMARY OF METHODS Facilities submitted lab data on positive urine and blood cultures in ICU patients through secure transmission to JSI. Files were screened for potential events that would be included in chart reviews. Procedure data from NHSN denominator files were also submitted to JSI, including discharge diagnosis codes for original procedure admission and all readmissions during the surveillance period. High risk codes associated with potential infections were flagged to select patients for SSI chart review.

5 SUMMARY OF METHODS Site visits for chart review took place between June and November One facility provided secure remote access to electronic medical records for the review. Reviewers were unaware of the event status of the cases during the review, to provide a blinded assessment. All facilities received feedback and the opportunity to discuss or contest the reviewers determinations. Several cases were submitted to CDC/NHSN for clarification.

6 OVERALL FINDINGS Comparison of current findings to previous validation: Current Previous CHANGES POST-VALIDATION: ( ) ( ) CASES REVIEWED REPORTED EVENTS (PRE-VALIDATION) ADD MODIFY DELETE 5 23 % CHANGE in total events + 15% + 23%

7 DEVICE-ASSOCIATED INFECTIONS IN ICU PATIENTS CAUTI* CLABSI# CHANGES POST-VALIDATION: CASES REVIEWED REPORTED EVENTS (PRE-VALIDATION) ADD 5 6 MODIFY 0 0 DELETE 0 1 % CHANGE in total events + 15% + 19% *catheter-associated urinary tract infection #central line-associated bloodstream infection

8 SURGICAL SITE INFECTIONS: CORONARY ARTERY BYPASS(CBGB) & COLON (COLO) CBGB* COLO CHANGES POST-VALIDATION: *Four facilities reporting on CBGB CASES REVIEWED REPORTED EVENTS (PRE-VALIDATION) ADD 1 16 MODIFY 2 5 DELETE 0 0 % CHANGE in total events + 9% + 23%

9 SURGICAL SITE INFECTIONS: ABDOMINAL HYSTERECTOMY(HYST) & KNEE ARTHROPLAST Y (KPRO) HYST KPRO CHANGES POST-VALIDATION: CASES REVIEWED REPORTED EVENTS (PRE-VALIDATION) ADD 0 5 MODIFY 3 6 DELETE 1 3 % CHANGE in total events -6% +7%

10 SURGICAL SITE INFECTION (SSI) ISSUES NHSN definitions have gotten stricter for organ space infections related to COLO and KPRO; prosthetic joint infection (PJI) and intra-abdominal abscess (IAB) have become more difficult to classify Post-discharge information from office visits, emergency care and cultures is sometimes overlooked by IP staff or missed by surveillance software. Present at time of surgery (PATOS) is misunderstood as an exclusion for subsequent SSIs. Despite the frequent definition updates and added specifics, some concepts are still confusing and open to interpretation.

11 CDC/NHSN CLARIFICATION: IAB DEFINITION QUESTION Intraabdominal infections must meet at least one of the following criteria: 1. Patient has organisms cultured from abscess and/or purulent material from intraabdominal space. 2. Patient has abscess or other evidence of intraabdominal infection on gross anatomic or histopathologic exam. 3. Patient has at least two of the following signs or symptoms: fever (>38.0 C±), nausea*, vomiting*, abdominal pain*, or jaundice* And at least one of the following: QUESTION TO NHSN: Does observing fecal material in the peritoneum during a reoperation to repair an anastomotic leak count as other evidence of intraabdominal infection??

12 CDC/NHSN CLARIFICATION: IAB DEFINITION ANSWER The observation of fecal-contents in the abdominal cavity alone does not indicate infection and cannot be used to meet the Organ/Space SSI or the IAB criteria for other evidence of infection. Also it does not meet the gross anatomic or histopathologic exam criteria. Based on the information provided and unless the patients had additional signs/symptoms or other evidence of infection, neither case meets SSI criteria.

13 CDC/NHSN CLARIFICATIONS Remember, the present on admission (POA) definition does not apply to the SSI protocol. If there was evidence of infection at the time of the procedure and then later in the surveillance period the patient develops an infection that meets the NHSN SSI criteria, it is attributed to the procedure. Infection present at time of surgery (PATOS) is not an exclusion for a patient later meeting SSI criteria. PATOS=yes is not an exclusion from reporting!

14 CDC/NHSN CLARIFICATIONS Infection present at time of surgery (PATOS): PATOS denotes that there is evidence of an infection or abscess at the start of or during the index surgical procedure. (PATOS is a YES/NO field on the SSI Event form.) The evidence of infection or abscess must be noted/documented intraoperatively in an intraoperative note (immediate postoperative note). The patient does not have to meet the NHSN definition of an SSI at the time of the primary procedure but there must be notation that there is evidence of an infection or abscess present at the time of surgery.

15 CDC/NHSN CLARIFICATIONS Infection present at time of surgery (PATOS): PATOS is not diagnosis driven (e.g. diverticulitis, peritonitis, and appendicitis). Identification of an organism alone using culture or non-culture based microbiologic testing method or on a pathology report from a surgical specimen does not = PATOS. Additionally, the following verbiage alone without specific mention of infection does not meet the PATOS definition: colon perforation, necrosis, gangrene, fecal spillage, nicked bowel during procedure, or a note of inflammation. PATOS can be met when an abscess is noted, there is mention of infection in the OR note, purulence or pus is noted, septic/feculent peritonitis is noted.

16 CDC/NHSN CLARIFICATIONS Regarding a possible CLABSI case in which facility considered positive blood cultures secondary to gastrointestinal infection(git), can Xray or ultrasound be used as diagnostic imaging tests? CDC s response: MRI and CT scans are examples of imaging diagnostic testing. e.g. is used to mean for example and show type of imaging as examples but doesn t limit to the ones specified. You may use any type imaging testing available to satisfy the criteria for imaging test evidence of infection. On the other hand, i.e. means specifically. In the equivocal imaging testing where we indicate you must have clinical correlation, the i.e. means we limit acceptable clinical correlation specifically to physician documentation of antimicrobial treatment for gastrointestinal infection.

17 QUESTIONS? Any questions or additional insights to share?